Ala. Admin. Code r. 610-X-6-.06 - Documentation Standards

Current through Register Vol. 40, No. 6, March 31, 2022

(1) The standards for documentation of nursing care provided to patients by licensed nurses are based on principles of documentation, regardless of the documentation format.
(2) Documentation of nursing care shall be:
(a) Legible.
(b) Accurate.
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, responses, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient. A signature of the writer, whether electronic or written, is required in order for the documentation to be considered complete.
(d) Timely.
(i) Charted at the time or after the care, to include medications. Charting prior to care being provided, including medications, violates principles of documentation.
(ii) Documentation of patient care that is not in the sequence of the time the care was provided shall be recorded as a "late entry," including a date and time the late entry was made, as well as the date and time the care was provided.
(e) A mistaken entry in the record by a licensed nurse shall be corrected by a method that does not obliterate, white-out, or destroy the entry.
(f) Corrections to a record by a licensed nurse shall include the name or initials of the individual making the correction.

Notes

Ala. Admin. Code r. 610-X-6-.06
New Rule: Filed October 29, 2001; effective December 3, 2001. Amended: Filed July 21, 2004; effective August 25, 2004. Adopted by Alabama Administrative Monthly Volume XXXIV, Issue No. 10, July 29, 2016, eff. 9/8/2016.

Author: Alabama Board of Nursing

Statutory Authority: Code of Ala. 1975, ยงยง 34-21 -1(3)(a), 34-21-1(3) (b), 34-21-2(c) (21) .

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